Thread by @ChecchiaPaul

1/ It is important to remember of one important fact: the delta variant is a VARIANT of SARS-CoV-2 virus; it is NOT a new virus. It still plays by the same rules. It still enters the body the same way. It still causes the same pathophysiology.

2/ It is still the exact same virus as we have been dealing with for the past 18 months (maybe more). It has changed a few amino acids within the receptor binding domain of the spike protein making it more infectious; but it has not fundamentally changed.

3/ This is important because a variant does not mean we literally throw away all the knowledge and experience we have gained over the past year and half. We have learned so much and now is not the time to retreat to ignorance.

4/ You see people running around like chickens without heads. This is not helpful; and it is not fair to the thousands of people who have dedicated countless hours of their time learning about what makes this infection tick.
Bottom line: take a breath and rely on what we know.

5/ [This post will be about adults and general data; I intend to put together a pediatric specific look over the next couple of days.]
1. Vaccines work. They all work. They all work exceedingly well. This includes the J&J shot.

6/ The report today about decreased J&J effectiveness highlights what I consider to be one of the biggest things we learned about medical publishing, the problem of the pre-print non-peer reviewed article.

7/ If it can only show up on a pre-print server, learn the lesson to take it with a grain of salt. It also highlights that we are forgetting all we learned about our immune system.

8/ Read this instead (theatlantic.com/.../coronaviru… ) We also know that previous infection from SARS-CoV-2 (regardless of variant) produces a complex and immune response.

9/ (please follow @MonicaGhandhi on twitter for a fantastic series of explanations) Vaccination in this setting, even with a single dose, is an amazing booster that provides stable and durable protection. Think of it as “belt and suspenders” (showing my age).

10/ 2. We know therapeutic interventions work to improve survival in severe COVID infection. I am continually struck with the success of our adult ICU colleagues have had over the past year in refining their approaches to the most critically ill patients.

11/ I have written about this in the past but let’s remember that they built the plane while in the air skirting the treetops and have come out on the other side with a highly functioning fighter jet.

12/ Currently, they approach every single ICU admission with the expectation that the patient, regardless of co-morbidities, will survive; not just the hope of such an outcome. Of course, it doesn’t always turn out that way, but it is no longer a resignation of death.

13/ To forget that cheapens their efforts, the lessons learned, and the knowledge gained. This is reflected by the continued fear-driven adage that “we know death spikes will come 2-4 weeks after a surge in cases.” No, we don’t know that.

14/ We used to, but today is way different than a year ago; let the COVID teams of caregivers do their work and continue to support them. (By the way, you can’t say that they were “healthcare heroes” last year but now question them as they advocate for vaccines.)

15/ 3. We know who is at higher risk. That risk profile has not changed. There are more admissions from younger people, but that is because they are the majority of the unvaccinated. They have become the vulnerable.

16/ However, there are no data available to support the idea that vulnerable conditions have fundamentally changed. Obesity, hypertension, older age, and lower socioeconomic factors are still the major determinants of poor outcomes.

17/ The UK data supports this as hospital admissions and deaths continue to be skewed to those populations (ons.gov.uk/.../coronaviru…).

18/ Data out of Israel supports the finding that breakthrough disease (NOT just PCR+ cases) are most likely found in those with hypertension and older age. [I will deal with “booster” vaccines in this group later.] (clinicalmicrobiologyandinfection.com/.../full... ) (bestlifeonline.com/news-vaccinate…)

19/ 4. Further, we have learned from previous experiences in the UK. There, just as in the US, the hospitalized population is nearly exclusively unvaccinated. Vaccinations protect against delta hospitalization and mortality.

20/ Specifically, let’s address the myth that the UK data shows that there is a greater risk of death if you are vaccinated. That is a claim made by people who simply are too stupid to do math (not surprising because they are also stupid in refusing the vaccine).

21/ Here is the source document in question. (assets.publishing.service.gov.uk/.../Variants_of... ). Please turn to page 17. You will see in the table that reports that 45.9% (118/257) of deaths occurred in individuals who had received 2 doses.

22/ However, only 2 occurred in younger (<50 yrs) and we have no data on the above co-morbidities of those older than 50. I’m attaching a simple image that I found on twitter that explains it so well.

23/ 5. We must not ignore or forget everything we have learned about the impact of vaccination on transmission. Again, it is not disputed that delta is more easily transmitted. However, let’s take a breath on all the rest.

24/ As I tried to outline above, there are no data available to support the idea that delta is more severe or “differently” severe.

25/ (I know, I am taking liberties with English grammar.) I would also put forth that there are no data available that changes the paradigm of vaccines significantly impacting asymptomatic transmission.

26/ Just prior to delta hitting the scene and sucking all the air out of the room, we started to have evidence that vaccinated individuals have a lower viral load, lower cycle count of replication, lower infectivity, and lower spread.

27/ Read this one:(academic.oup.com/.../10.1093/of…)

And then these as well:
(nejm.org/doi/full/10.10…... )
(nejm.org/doi/full/10.10…)

28/ The studies are well done, they represent the variants, they demonstrate an over 50% reduction in the ability to transmit to other people EVEN AFTER 1 DOSE, and they all hedge to say that real world results are likely even better than what they all measured.

29/ I want to just put forth a note of equipoise and state that there is no evidence that I can find to support fully abandoning that way of thinking, with a significant caveat. That caveat has to do with symptomatic vs asymptomatic vaccinated individuals.

30/ This is where I also implore each of us to not forget the lessons of nuance that we have learned over the past year.

31/ I would put forth that a symptomatic, fully vaccinated individual likely has an increased risk of transmission; increased but from a markedly depressed baseline.

32/ Second, I contend that there are no data to dissuade me from thinking that an asymptomatic, fully vaccinated individual still has up to a 90% decreased risk of transmission: like the above reports.

33/ Thus, if you have symptoms of fever, cough, and fatigue and you are fully vaccinated, I would assume that you can transmit easier than with other variants; easier but still not guaranteed.

34/ I am overtly and purposefully avoiding the mask discussion at this point not due to being afraid of the conversation, but only because it is compounding unknowns. We have absolutely no good data on just how much masks impact delta spread in vaccinated individuals.

35/ If someone can find data (not assumptions or fear, but data) I would love to see it.
6. Final point.

36/ The biggest lesson we learned over the past 18 months is that an incredible number of fantastic scientists have been working diligently in the background on the vaccines we have today.

37/ They toiled in labs with limited funding while basically nobody but their families and grad students were watching. They spent over a decade learning about how to deliver mRNA to our bodies in a vaccine form. We learned of their work over the past year.

38/ We learned of their successes. We learned of the gift of science, God, humans, and medicine that are the vaccines we have today. We learned that they are wildly successful and safe.

39/ We also learned the lesson that the unvaccinated face the hardest of lessons; those of sickness, loss, and the pain of recovery.
Delta is not unique, but it continues to be a teacher…will we continue to learn?

@MonicaGandhi9 Sorry that I tagged you incorrectly in the thread above. This reply is meant to correct that.